Complications in Pregnancy Flashcards
what is the aetiology of miscarriages?
> unknown
abnormal conceptus (structural, genetic, chromosomal)
uterine abnormalities (fibroids, congenital)
maternal (increasing age, diabetes)
cervical incompetence
what is an incomplete miscarriage?
most of the pregnancy has been expelled but some of the material is still in the uterus
how does an incomplete miscarriage present?
> heavy bleeding
> open cervix
what is a threatened miscarriage?
a viable pregnancy but with vaginal bleeding (+/- pain) and a closed cervix
how may an inevitable miscarriage present?
> open cervix
> heavy bleeding with clots
what management may an inevitable miscarriage need?
evacuation if bleeding heavily
how does a missed miscarriage present?
no symptoms or bleeding
how is a missed miscarriage investigated?
Ultrasound
> empty gestational sac
> no foetal heart
how is a missed miscarriage managed?
> conservative
surgical
medical prostaglandins
what is a miscarriage?
termination/loss of pregnancy before 24 weeks gestation
what is a septic miscarriage?
infection secondary to miscarriage
how is a septic miscarriage managed?
> evacuation
> antibiotics
what is a complete miscarriage?
all products of conception passed
how does a complete miscarriage present?
> bleeding stopped
> cervix closed
what are some risk factors of ectopic pregnancy?
> pelvic inflammatory disease
previous ectopic
previous tubal surgery
assisted conception
what is an ectopic pregnancy?
pregnancy implanted outside the uterine cavity
how does an ectopic pregnancy present?
> amenorrhea (+ve test)
vaginal bleeding
abdominal pain
GI/urinary symptoms
how is an ectopic pregnancy investigated?
> scan (no in-uterine gestational sac, adnexal masses, fluid in pouch of douglas)
serum BHCG levels over 24 hours
serum progesterone levels (25mg/ml is viable pregnancy)
what is the management if ectopic pregnancy?
> methotrexate
> surgical salpingectomy or salpingotomy
what is antepartum haemorrhage?
haemorrhage from the genital tract after week 24 but before delivery
what local lesions can cause antepartum haemorrhage?
> erosions
polyps
cancer
what is vasa praevia?
rupture of the foetal vessels causing antepartum haemorrhage
what is placenta praevia?
all or some of the placenta implants in the lower part of the uterus
what are some causes of antepartum haemorrhage?
> local lesions
vasa praevia
placenta praevia
placental abruption
what are the risk factors for placenta praevia?
> multiparous women
multiple pregnancies
previous c-section
what are the classifications of placenta praevia?
- placenta encroaching on the lower segment. not in int. cervical os
- placental reaches internal cervical os
- placenta eccentrically covers the os
- central placenta praevia
how does placenta praevia present?
> PAINLESS PV BLEEDING
malpresentation of the foetus
soft non-tender uterus
how do you diagnose placenta praevia?
> ultrasound scan
how is placenta praevia managed?
> C-section > PPH management - carbaprost - ergometrinas - tranexamic acid - surgical ligation of arteries or hysterectomy
what are the risk factors for placental abruption?
> pre-eclampsia > multiple pregnancy > parity > smoking > polyhydramnios > previous abruptions
what is placental abruption?
haemorrhage from premature placenta separation
how does placental abruption present?
> bleeding
pain
increased uterine activity
what are the complications of placental abruption?
> PPH
foetal death
maternal shock (DIC/renal failure)
what different types of placental abruption?
> mixed
concealed: uterus increases in height, blood escaping between placenta and uterine wall
revealed: blood externally escaping
what is preterm labour?
onset of labour before 37 weeks of completed gestation
what are the risk factors for preterm labour?
> multiple pregnancies > polyhydramnios > pre-eclampsia > APH > infection > prelabour premature rupture of the membranes > idiopathic
what is extremely preterm labour?
24-28 weeks
what is very preterm labour?
28-32 weeks
what is mildly preterm labour?
32-36 weeks
how do you diagnose preterm labour?
> contractions
> evidence of cervical change on VE
what is the management of preterm labour?
> transfer to unit with NICU
aim for vaginal delivery
consider tocolysis, allow steroid unless contraindicated
what is chronic hypertension?
hypertension at pre-pregnancy
what is mild chronic hypertension?
90/140
what is chronic moderate hypertension?
100/150
what is severe chronic hypertension?
110/160
what is the management for chronic hypertension in pregnancy?
> aim for <150/100
> monitor for pre-eclampsia and foetal growth
what is pre-eclampsia?
mild hypertension on 2 occasions more than 4 hours apart plus proteinuria of >300mgms/ 24 hours
what are the risk factors for pre-eclampsia?
> first pregnancy > multiple pregnancy > family history > more than 10 years between pregnancy > extremes of age > underlying medical disorders - chronic hypertension - renal disease - diabetes - autoimmune disorders
what is the pathophysiology in pre-eclampsia?
> imbalance in vasodilation and vasoconstriction
> secondary invasion of maternal spinal arteries by trophoblasts impaired so there is decreased placental perfusion
what are the investigations for pre-eclampsia?
> BP and urine > CTG > U+E's > LFT's > Bloods
how does pre-eclampsia present?
> seizures > reduced urine output > severe hypertension and urine proteinuria > vomiting > swelling of hands, face and legs > headache > blurred vision > epigastric pain
what changes in biochem investigations are seen in pre-eclampsia?
> increased liver enzymes
bilirubin
increase urate
increased urea
what changes in haematological investigations are seen in pre-eclampsia?
> decreased platelets
decreased haemoglobin
DIC features
what complications of pre-eclampsia are there?
> impaired placental perfusion > cardiac failure > pulmonary oedema > renal failure > disseminated intravascular coagulopathy > HELLP > severe hypertension > eclampsia
what is the conservative management of pre-eclampsia?
> steroids
aim for foetal maturity
anti-hypertensives
what is the management for pre-eclampsia?
induction of labour or c-section
what is the management for eclampsia and PET?
> seizure control
- avoid fluid overload
- control of BP (IV labetolol)
- magnesium sulphate bolus and IV infusion
prophylaxis in subsequent pregnancies
- low dose aspirin from 12 weeks until delivery
how does a venous thrombo-embolism present?
> tachycardia
hypoxic
calf pain and swelling
breathlessness, cough, dyspnoea
what investigations should be carried out in a venous thrombo-embolism?
> ECG > blood gases > doppler > V/Q scan > CT pulmonary angiogram
what are the risk factors in a venous thrombo-embolism?
> previous VTE > sickle cell disease > haemorrhage > prolonged delivery > decreased mobility > dehydration > infections > PET > smoking > older mothers > PWID > increased BMI
what prophylaxis is there for a venous thrombo-embolism event?
> increasing mobility
TED stockings
hydration
anticoagulation 6 weeks post partum if 3 or more risk factors
what causes increased stasis in pregnancy?
> progesterone
> enlarging uterus
what causes a hypercoagulable state on pregnancy?
> increased fibrinolysis
increased fibrinogen
decreased natural anticoagulant (antithrombin 2)
what are the risk factors for gestational diabetes?
> BMI >30 > previous macrocosmic baby > previous GDM > high diabetic risk > family history of diabetes > polyhydramnios current pregnancy > recurrent glycosuria in pregnancy
how screening is there for gestational diabetes?
> oral glucose tolerance test at 16 weeks and repeat at 28 weeks if there are significant risk factors
offer HbA1C estimation (if more than 6% off OGTT)
what is the management for gestational diabetes?
> control of the blood sugar (diet, metformin or insulin)
post delivery: check OGTT at 6-8 weeks
yearly check of HbA1C if at higher risk
what hormones significant in pregnancy have anti-insulin actions?
> HCG
cortisol
human placental lactogen
progesterone
what does foetal hyperinsulinemia lead to?
macrosomia
what are some complications of pre-existing diabetes in pregnancy?
> foetal congenital abnormalities > miscarriage > foetal macrosomia > shoulder dystocia > reduced awareness of hypoglycaemia > pre-eclampsia > infection > still birth > neonatal - jaundice - impaired lung maturity - hypoglycaemia
what preconception management is available for diabetes in pregnancy?
> glycaemic control (HbA1C <6.5%)
folic acid 5mg
dietary advice
retinal and renal assessment
what management is available for diabetes during pregnancy?
> aware of the hypo. risk > watch for infection > may need to change to insulin > labour - usually induced at 38-40weeks - insulin - early feeding of the baby - continuous ECG - C-section due to macrosomia
